臺灣博碩士論文加值系統

背景：
隨著社會結構、飲食與生活習慣的改變，2012年全世界20-79歲糖尿病盛行率佔8.5%，呈現逐年上昇的趨勢，糖尿病是眾多慢性病中，對個人健康最具威脅性的疾病。足部周邊神經病變是糖尿病常見的併發症，導致病患、家庭與社會的重大負擔，是公共衛生重要議題之一。

目的：
為了解中部某縣社區糖尿病足部周邊神經病變的情形，並探討糖尿病足部周邊神經病變相關危險因子，本研究是藉由衛生所基層資料，針對造成糖尿病周邊神經病變危險因子能早期發現、早期做好預防措施，進而降低糖尿病足部病變的發生率及截肢率。

方法：
採用橫斷性研究方法，資料來源為某縣「糖尿病共同照護網資訊系統」次級資料，取樣自2009年至2012年糖尿病收案持續管理至少滿2年之個案(3,530人)。本研究分析2011年至2012年照護期間足部神經病變篩檢資料；探討足部神經病變情形及相關危險因子。分析社會人口學特徵、實驗室檢查資料、醫療行為、疾病史、健康行為等因子對周邊神經病變的影響。本研究以SAS 9.3版之統計軟體統計分析，單變項分析使用百分比、平均值、標準差描述各類別變項，相關性統計將使用卡方檢定，多變項分析將應用邏吉斯迴歸(Logistic Regression analysis)等統計分析。

研究結果：
研究結果發現，有2432位納入研究對象，有288位為糖尿病足部周邊神經病變篩檢異常，周邊神經病變盛行率為11.84%，糖尿病罹病年5-9年佔最多。男性周邊神經病變顯著高於女性1.71 (95%CI 1.21-2.41)；50-65歲及65歲以上周邊神經病變顯著高於50歲以下2.89(95%CI 1.02-8.15)及6.45 (95%CI 2.31-18.05)；教育程度不識字者周邊神經病變顯著高於識字1.67 (95%CI 1.23-2.28)；依個管院所在地分都巿化層級第二層與第三層周邊神經病變顯著高於第一層1.66(95%CI 1.08-2.55)及4.38 (95%CI 2.96-6.48)；糖尿病罹病年10年以上周邊神經病變顯著高於10年以下1.37 (95%CI 1.04-1.79)；有腦中風周邊神經病變顯著高於無腦中風3.75(95%CI 1.60-8.80)。血壓異常周邊神經病變顯著高於血壓正常1.65 (95%CI 1.26-2.16)；糖化血紅素9%以上周邊神經病變顯著高於糖化血紅素9%以下1.65(95% CI 1.13-2.41)；慢性腎病分期第五期周邊神經病變顯著高於慢性腎病分期第五期以下6.54 (95%CI 1.27-33.66)。

研究結論
本研究糖尿病周邊神經病變重要影響因素為男性、年齡>50歲、不識字、都巿化層級愈高、糖尿病罹病年10年(含)以上、有腦中風病史、血壓異常、糖化血紅素9%(含)以上、慢性腎病分期第五期以上。控制血壓及血糖可延緩糖尿病足部周邊神經病變，建議糖尿病病患養成每日自我測量血壓，每周至少1次自我監測血糖，且記錄血壓值和血糖值的習慣，每年接受至少一次護理和營養衛教，接受一次足部病變篩檢，本研究結果可作為臨床在社區糖尿病足部神經病變衛教之參考。
關鍵詞：糖尿病、周邊神經病變、盛行率

Background：
Diabetes is one of the most threatening chronic diseases on personal health disorders. Foot peripheral neuropathy is a common complication of diabetes. It causes many burdens on patients, their families, and the society. With the changes in modern society, diet and lifestyle, the 2012 worldwide prevalence of diabetes is 8.5% among the age group of 20-79. It is also showing an increasing trend. How to deal with diabetic foot related problems is one of the important issues of public health.

Objective：
The study purpose is to understand the situation of diabetic foot peripheral neuropathy in a county, and to explore the risk factors associated with peripheral neuropathy.

Methods：
By extracting the data from "Diabetes Care Network Information System" (DCNIS)" of a County Health Bureau located at central Taiwan, there were 3,530 diabetic patients having their two years case management continuously from 2009 to 2012. (ICD-9 -CM 250.XX). This study would explore the situation of foot neuropathy and its associated factors in the period of year 2011 to 2012 by a cross-sectional design. The socio-demographic characteristics, foot screening examination, laboratory data, patients’ self-care behaviors and the degree of adherence compliance in medical care, would be treated as associated risk factors. All study variables would be tracked back from year 2002 to 2012 in DCNIS, including foot screening, laboratory examination, nursing health education, and nutrition health education. SAS 9.3 for windows would be used to analyze the data and the statistical methods would include descriptive statistics, chi-square test, and the logistic regression model.

Results：
The results found that 2432 patients in the study. There were 288 patients with abnormal peripheral neuropathy through diabetic foot screening. The prevalence was 11.84%. The disease duration was mainly between 5 and 9 years. Male peripheral neuropathy was significantly higher than females with odds ratio, 1.71 (95% CI 1.21-2.41). There was significantly higher risk for aged 50-65 and over 65 comparing to aged under 50, with odds ratio 2.89 (95% CI 1.02-8.15) and 6.45 (95% CI 2.31-18.05) respectively. Lower education level had higher risk with odds ratio 1.67 (95% CI 1.23-2.28). Lower urbanization also had higher risk with odds ratio, the moderate urbanization and lowest urbanization with odds ratio 1.66 (95% CI 1.08-2.55) and 4.38 (95% CI 2.96-6.48) respectively (the highest urbanization as reference group). Duration of diabetes over 10 years showed higher risk with odds ratio 1.37 (95% CI 1.04-1.79). Patients with stroke history also showed higher risk with odds ratio 3.75 (95% CI 1.60-8.80). Patients with abnormal blood pressure had higher risk with odds ratio 1.65 (95% CI 1.26-2.16). If patients had glycohemoglobin more than 9%, they had higher risk with odds ratio 1.65 (95% CI1.13-2.41). If patients had stage 5 chronic kidney disease, they also had higher risk with odds ratio 6.54 (95% CI 1.27-33.66).

Conclusion
Our study points out that the related factors of diabetic peripheral neuropathy included: male, age more than 50 years old, low education, low urbanization, duration of diabetes more than 10 years, history of stroke, abnormal blood pressure, glycohemoglobin greater than 9% and stage 5 chronic kidney disease. Control of blood pressure and blood sugar can delay diabetic foot peripheral neuropathy process. Regular check and keeping the record, daily self-measurement of blood pressure and at least once a week of self-monitoring of blood glucose, is suggested, especially for diabetic patients. Nurse/nutrition health education and foot lesions screening at least once a year is also very important to provide the best protection for diabetic patients to prevent potential diabetic peripheral neuropathy diseases.

目錄
誌謝 I
中文摘要 II
ABSTRACT V
表目錄 XI
圖目錄 XII
第一章 緒論 1
第一節 研究背景與研究動機 1
第二節 研究目的與研究重要性 4
第三節 研究問題與研究假設 5
第四節 名詞界定 6
第二章 文獻查證 8
第一節 糖尿病周邊神經病變流行病學 8
第二節 全民健保糖尿病醫療給付改善方案 12
第三節 足部周邊神經功能檢測方法 15
第四節 研究架構 18
第三章 研究方法 20
第一節 研究設計 20
第二節 研究對象 21
第三節 資料來源 22
第四節 資料收集過程 24
第五節 資料統計與分析 33
第四章 研究結果 34
第一節 有納入的研究對象於各變項之分佈 34
第二節 有無納入研究對象於各變項之分佈及其差異 35
第三節 有無病變研究對象於各變項之描述性統計及其差異 36
第四節 有無截肢研究對象於各變項之描述性統計及其差異 38
第五節 影響糖尿病足部神經病變相關的邏吉斯迴歸分析 39
第五章 討論 59
第一節 糖尿病足部周邊神經病變盛行率 60
第二節 糖尿病足部周邊神經病變最重要影響因素 61
第三節 糖尿病足部周邊神經病變社會人口學影響因素 62
第四節 糖尿病足部周邊神經病變疾病史影響因素 63
第五節 糖尿病足部周邊神經病變生理、生化檢查影響因素 64
第六節 糖尿病足部周邊神經病變健康行為影響因素 65
第七節 糖尿病足部周邊神經病變醫療行為影響因素 65
第六章 結論與建議 66
第一節 結論 66
第二節 研究限制 67
第三節 建議 68
參考文獻 70
附錄 80
附錄一、基本資料 80
附錄二、實驗室檢查紀錄表 81
附錄三、護理衛教紀錄表 82
附錄四、營養衛教紀錄表 83
附錄五、下肢衛教紀錄表 84
附錄六、視網膜篩檢轉診單 86

表目錄
表 2- 1 糖尿病周邊神經病變盛行率 9
表3- 1 2009、2010、2011、2012年各年初在案管理清冊 25
表3- 2 2009、2010、2011、2012年個案管理消長情形 26
表3- 3 未納入研究對象 (2009-2012年度未連續2年在案，照護<1年) 27
表3- 4 納入研究對象(於2009-2012年度連續2年(含)以上在案，照護≥1年) 28
表3- 5 2009年3,150在案個案連續4年就醫順從性分析 29
表3-6 實驗室檢查資料極大極小不合理值處理 32
表4- 1 有無納入研究對象社會人口學特質分析 42
表4- 2有無納入研究對象疾病史分析 44
表4- 3 有無納入研究對象健康行為分析 45
表4- 4 有無病變研究對象社會人口學特質分析 46
表4- 5 有無病變研究對象疾病史特質相關性分析 48
表4- 6有無病變研究對象健康行為相關性分析 49
表4- 7 有無病變研究對象生理、生化各項檢查相關性分析 50
表4- 8有無病變研究對象醫療行為各項檢查相關性分析 52
表4- 9足部有無截肢相關性分析 53
表4- 10影響糖尿病足部神經病變相關因素的邏吉斯迴歸分析 54
表4- 11影響糖尿病足部神經病變相關因素之邏吉斯迴歸分析(最適模式) 58

圖目錄
圖 2- 1 研究架構 19
圖 3- 1 納入研究對象說明 21
圖 3- 2 納入研究對象流程 30
圖 3- 3 糖尿病足部周邊神經變研究對象擷取流程 31

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